Contact Sheet - Hope Center
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1
2CONTACT SHEET
Participant Name
__________________________________
(First Name, Last Initial)
Advocate Initials _______ Date of Contact _____________ Time
TYPE of CONTACT
LOCATION
Crisis Line
Faribault
St Olaf
Business Line
Northfield
Carleton
Drop In Center
Rural
Group
Dundas
Court
Lonsdale
Out of County
Other in Person
Morristown
Unknown
Written/E-mail
Nerstrand
CASE STATUS:
New
Continuing
Renewing, first contact this year
(starts July 1)
VICTIM CLASS:
Primary
Secondary
**Note: Children of battered
women are PRIMARY victims
GENDER:
Female
Male
Unknown
AGE
:
CHILD
ADULT
Referral from:
0-4 years
18-29 years
5-12 years
30-44 years
13-17 years
45-64 years
Unknown Child
+65 years
Unknown Adult
RACE/ETHNICITY
:
African American
American Indian
Asian/Pacific Islander
Caucasian/White
Chicano/Latino
Multi-racial
Immigrant (specify origin)
__ Mexico/Central & So. America
__ Middle East
__ Africa
__Asia
__Europe
__Other/Unknown Immigrant
Other/Unknown Race
DISABILITY:
Blind/Visually Impaired
Deaf/Hard of Hearing
Physically Disability
Developmental Disability
Mental Illness
Other
___________
(Specify)
Revised 2/8/06
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